‘Catalogue of errors’ led to surgery death
THE FAMILY of a patient who died after the first robotic heart operation of its kind in the UK said lessons must be learned from the “catalogue of errors” that were made.
Following an inquest into the death of Stephen Pettitt, 69, it emerged that Newcastle Hospitals NHS Foundation Trust had dismissed Sukumaran Nair, the lead surgeon for the procedure at the Freeman Hospital.
In February 2015, father-ofthree Mr Pettitt was the first person in the UK to undergo robotic mitral valve surgery, but after a lengthy operation which had to be completed with conventional open heart surgery, he died from multiple organ failure.
His family released a statement yesterday saying an investigation revealed “a catalogue of errors including significant deficiencies in training and competence of the surgeon who had performed the procedure, who was subsequently dismissed”.
The inquest in Newcastle heard an expert’s opinion that Mr Pettitt would have stood only a one to two per cent chance of dying had conventional, open heart surgery been used instead.
Mr Nair had no face-to-face training on using the robot before he operated on Mr Pettitt, but had watched similar procedures in the US and Holland and practised alone on a simulator.
Trained experts in using the Da Vinci robot, known as proctors, were in the theatre to help, but left before the complex procedure finished.
It was made more complicated and lengthy by sutures being found to be misaligned and the robot camera becoming blinded with blood.
It emerged on the last day of the inquest that these proctors, who flew in from outside the UK, could not have stepped in as they were not registered with the General Medical Council. The inquest also found the operating team had not agreed the point after which robotic surgery should be converted to open heart surgery.
Coroner Karen Dilks gave a narrative conclusion, saying: “Mr Pettitt died due to complications of an operation to treat mitral valve disease and, in part, because the operation was undertaken with robotic assistance.”
She will write to Newcastle Hospitals NHS Foundation Trust with a series of recommendations about how its policies could be improved in the light of the operation. These include how proctors are recruited and making sure there was clarity over what was expected.
She will also contact the Royal College of Surgeons and the Department of Health asking them to consider whether national guidelines should be brought in.
Northumbria Police launched a criminal investigation but no criminal charges were brought.
After the inquest, Dr Andy Welch, medical director for the hospitals trust, issued a “heartfelt apology” to Mr Pettitt’s widow.
He said the robotic heart programme was stopped immediately and significant changes had been made, with the trust having largely addressed the issues raised by the coroner.